UCSD EXPERIENCE, DESIGNING AND IMPLEMENTING CORRECTIVE ACTIONS. Derek Brown

Transcription

1 UCSD EXPERIENCE, DESIGNING AND IMPLEMENTING CORRECTIVE ACTIONS Derek Brown

2 2 Design and implementation of corrective actions Outline 1. Designing corrective actions Something has gone wrong, what are you going to do about it? 2. Implementing corrective actions Generating buy-in and promoting behaviour change

3 A brief story

4 The pitch

5 The hit

6 The (failure mode) effect

7 The reaction Oh shoot!!

8 The feedback What the?

9 The corrective action

10 Let s play ball!

11 The pitch

12 The hit

13 The next (failure mode) effect

14 The learning

15 Designing corrective actions 15 There are three commonly used options for designing corrective actions 1. Option 1 Re-invent the wheel Start from scratch and make up your own corrective action 2. Option 2 Beg, borrow, and steal See what other people have used as corrective actions and choose one of these 3. Option 3 Progressive adaptation Take what s already been done and modify it for your unique situation

16 Option 1 - Re-invent the wheel 16 Why this is a good idea 1. This is a great way to improve multi-disciplinary communication and teamwork in the clinic. 2. Remember that everybody wants a safer, better workplace and that everybody wants to contribute to this effort. 3. Unfortunately, at a very detailed level, most clinical processes are unique, re-inventing the wheel ensures you get a solution that is applicable to your unique process.

17 Option 1 - Re-invent the wheel 17 Why this is a bad idea 1. This takes a lot of time and effort. 2. Immediately after the incident, motivation will be high, but quickly wanes if the perception is that there is not a lot of progress being made. 3. You could get it fantastically wrong. Your corrective action may be completely ineffective You might actually make things worse, or cause problems elsewhere in the clinic.

18 Option 2 Beg, borrow, and steal 18 Why this is a good idea 1. This could be really quick and easy. 2. Allows you to strike while the iron is hot to implement change while motivations are high. 3. Potentially increases the chances that the corrective action is effective at least two groups think it s a good idea. Maybe someone has even demonstrated (published) that the corrective action is effective.

19 Option 2 Beg, borrow, and steal 19 Why this is a bad idea 1. Your process is definitely a little bit different and may be very different from the clinic where the corrective action was shown to be effective. You may be making things worse at your clinic by implementing a corrective action that has been proven to be effective in another clinic. 2. Risk perception of being a dictatorial leader. 3. There s a missed opportunity for teambuilding/for improving multi-disciplinary communication. 4. It s hard to know what corrective actions others have implemented.

20 Option 3 Progressive adaptation 20 Why this is a good idea 1. Take something that someone else has proven to be effective and adapt it for use in your process. 2. Medium time and effort required potentially can still strike while the iron is hot. 3. Great opportunity for teambuilding. 4. Great opportunity for improving multi-disciplinary communication.

21 Option 3 Progressive adaptation 21 Why this is a bad idea 1. It s hard to know what corrective actions others have implemented.

22 What corrective actions are available? 22 We need a list of corrective actions comprehensive summary of corrective actions classified using some sort of taxonomy ranked according to effectiveness/resources Luckily, this list is forthcoming Brainchild of Steve Sutlief We ve looked at over 1000 reported RO-specific corrective actions

23 Corrective Action Taxonomy: Context-, Role-, Hazard-, Causal based 23 Process Step (location) Patient assessment Imaging for RT planning Treatment planning Role Hazard Physician Elimination Physicist Substitution Dosimetrist Engineering Therapist Administration Causal Organizational management Technical Individual actions Second Level Policies, procedures, regulations Training; sharing knowledge Leadership & external controls Physical Environment Accept. testing, commissioning Equipment design Equipment maintenance Environment (ergonomic) Staff behaviors Patient circumstances Sutlief, Brown AAPM 2014

24 Distribution of Corrective Actions 24 Safety barrier Other Training Exhortation QA Program Supervision High level change Process standardization

25 The two most commonly used corrective actions are 2% 1. More Hand Washing and Less Texting 9% 1% 88% 1% 2. Supervision and High Level Change 3. Exhortation and Punishment 4. Safety barriers and Training 5. Less Hand Washing and More Texting

26 The two most commonly used corrective actions are 1. More Hand Washing and Less Texting 2. Supervision and High Level Change 3. Exhortation and Punishment 4. Safety barriers and Training 5. Less Hand Washing and More Texting Sutlief, Brown, AAPM 2014

27 Implementing Corrective Actions Let s split this up into 1. Safely implementing corrective actions 2. Effectively implementing corrective actions These can sometimes be at odds Take so long to figure out how to safely implement something that people no longer remember the problem 2. Implement a corrective action that everybody loves but causes negative downstream effects

28 Safely Implementing Corrective Actions This is really about 1. making sure that the corrective action will address the problem you are having 2. making sure you don t make things worse - understanding downstream effects Must include some sort of hazard analysis Sit down with your multi-disciplinary team and try to figure out everything that could possibly go wrong You can t imagine everything that will go wrong

29 Safely Implementing Corrective Actions Implementation Test the corrective action in a mock setting Test the corrective action in a mock setting again! Roll out the corrective action in a step-wise fashion Seek feedback and be open to change

30 Effectively Implementing Corrective Actions This is really about 1. generating buy-in from those who are directly effected, 2. understanding corrective actions as behavior changes. Generating buy-in and promoting behavior change If you don t have this part figured out, your corrective action is destined to fail!! I promise.

31 Generating buy-in and promoting behaviour change Helps to ensure that... Your fancy new corrective action is adopted Is persistent (even past the initial newlywed phase) So then the questions is How do you this?

32 Generating buy-in and promoting behaviour change My thoughts... Involve as many stakeholders in the process as possible/reasonable Value all of their opinions equally Communicate way more than you think might be necessary Be ready to accept that your first solution is very unlikely to be the best it will need to be modified What do the experts say?

33 How do you promote behavior change? Strategies for assisting health workers to modify and improve skills. World Health Organization, Predisposing strategies 2. Enabling strategies 3. Strategies for reinforcing behavior change 4. Strategies used at the team level

34 Promoting behavior change 1. Predisposing strategies Educational materials Conferences Outreach visits Local opinion leaders Self assessment Strategies for assisting health workers to modify and improve skills: Developing quality health care, a process of change Woodward, WHO, 2000

35 Promoting behavior change 1. Predisposing strategies Educational materials Conferences Outreach visits Local opinion leaders Self assessment Strategies for assisting health workers to modify and improve skills: Developing quality health care, a process of change Woodward, WHO, 2000

36 Promoting behavior change 2. Enabling strategies Practice rehearsal Clinical guidelines and care maps Reminders

37 Promoting behavior change Practice rehearsal Providing opportunities to rehearse new skills within the context of a continuing education event has been shown to produce positive results. (Kottke, Brekke,Stolberg & Hughes, 1989) Clinical guidelines and care maps In a review of 59 studies, all but 4 found positive change in behavior with the use of clinical guidelines. Clinician involvement and focused educational events are predictors of success.

38 The use of clinical guidelines and care maps 9% 17% 72% 1% 2% 1. Has been shown to be ineffective 2. Warrants further study 3. Has been shown to be highly effective 4. Is something that we should leave to hospital CEOs 5. Is not of interest in radiation oncology

39 The use of clinical guidelines and care maps 1. Has been shown to be ineffective 2. Warrants further study 3. Has been shown to be highly effective 4. Is something that we should leave to hospital CEOs 5. Is not of interest in radiation oncology Strategies for assisting health workers to modify and improve skills: Developing quality health care, a process of change Woodward, WHO, 2000

40 Promoting behavior change Reminders These are essentially checklists or time-outs and have been shown to be effective in changing behavior improving compliance with clinical protocols

41 Reminders and checklists 1% 1. Are commonly perceived as a waste of time 7% 88% 2% 3% 2. Are known to be ineffective 3. Can improve compliance with clinical protocols 4. Are the most likely cause of future incidents 5. Are designed deliberately by management to force everyone to do more paperwork

42 Reminders and checklists 1. Are commonly perceived as a waste of time 2. Are known to be ineffective 3. Can improve compliance with clinical protocols 4. Are the most likely cause of future incidents 5. Are designed deliberately by management to force everyone to do more paperwork N Engl J Med Dec 28;355(26): An intervention to decrease catheter-related bloodstream infections in the ICU. Pronovost P

43 Promoting behavior change 3. Strategies for reinforcing behavior change Audit and feedback Peer review

44 Promoting behavior change 4. Strategies used at the team level Development of quality improvement (QI) teams QI teams have been shown to have positive impacts on quality in healthcare (Laffel, 1986; Berwick, 1990; Burns, 1992)

45 The development of QI teams 1% 71% 19% 9% 0% 1. Is one way to get people excited about coming to work 2. Is one way to promote behavioral change 3. Is a reasonable substitute for monitoring quality indicators 4. Is absolutely necessary in a singlephysicist clinic 5. Is unlikely to be effective

46 The development of QI teams 1. Is one way to get people excited about coming to work 2. Is one way to promote behavioral change 3. Is a reasonable substitute for monitoring quality indicators 4. Is absolutely necessary in a single-physicist clinic 5. Is unlikely to be effective Strategies for assisting health workers to modify and improve skills: Developing quality health care, a process of change Woodward, WHO, 2000

47 Summary 47 We ve looked at how to design corrective actions Progressive adaptation List of corrective actions forthcoming We ve looked at how to implement corrective actions Safely hazard analysis and testing Effectively generating buy-in and promoting behaviour change